Transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) in the treatment of single-level lumbar spondylolisthesis

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R E S E A R C H

Open Access

Transforaminal lumbar interbody fusion

(TLIF) versus posterior lumbar interbody

fusion (PLIF) in the treatment of single-level

lumbar spondylolisthesis

Essam Moneer Ali Rezk

*

, Ahmed Rizk Elkholy and Ebrahim Ahmed Shamhoot

Abstract

Background:Various surgical procedures have been recommended for the treatment of lumbar spondylolisthesis, but controversy still exists regarding the optimal surgical technique. In this study, we compared the clinical and radiologic outcomes of posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) with pedicle screw fixation in the treatment of single-level lumbar spondylolisthesis.

Methods:Ninety-four patients underwent lumbar interbody fusion with pedicle screw fixation for the treatment of adult lumbar spondylolisthesis. Forty-six had PLIF with two cages and pedicle fixation (group 1), and 48 had TLIF with one cage and pedicle fixation (group 2). The follow-up was performed clinically using the visual analog scale (VAS) and Oswestry Disability Index (ODI) Questionnaires. Outcome scores were assessed 3, 6, and 12 months after surgery. Radiographs were obtained postoperatively and at regular intervals for 6 months. Perioperative outcomes such as surgery time, blood loss, length of hospital stay, and incidence of surgical complications were also recorded.

Results:Estimated blood loss and operative time in the TLIF group were significantly lower than those in the PLIF group. VAS for back pain and ODI were significantly better in the TLIF group than the PLIF group. However, at the time of the last follow-up, both groups had similar slip reduction and spinal fusion rates. More complication rate was encountered in the PLIF group compared to the TLIF group.

Conclusions:Our study showed that TLIF is superior to PLIF with respect to functional outcome and complication rate in grade I/II single-level lumbar spondylolisthesis.

Keywords:Lumbar spondylolisthesis, Posterior lumbar interbody fusion (PLIF), Transforaminal lumbar interbody fusion (TLIF)

Introduction

Spondylolisthesis (spondylos = vertebrae; listhesis = slip-page) is defined as the forward slippage of one vertebra on another [1]. Of its 5 subtypes, degenerative and isthmic spondylolisthesis are the most common in adults [2].Both can lead to compression and instability, which result in radicular and low back pain [3].

Surgical fusion is a crucial method for stabilizing the spine in cases of lumbar spondylolisthesis; it is used to

reduce the pain in patients with chronic low back pain [4]. Different surgical fusion techniques are currently available including anterior interbody fusion, posterior interbody fusion, posterolateral fusion, and repair of the pars interarticularis [5–9].

PLIF or TLIF can achieve a circumferential spinal stabilization by the placement of pedicle screws and an interbody spacer through a single posterior ap-proach [10–12]. There is no definitive evidence for one approach being superior to the other in terms of fusion or clinical outcomes [13].

© The Author(s). 2019Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

* Correspondence:es_moneer2000@yahoo.com

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The current study is a retrospective clinical case series aiming to compare the surgical results of PLIF and TLIF in the treatment of low-grade spondylolisthesis.

Patients and methods

Patient population and selection criteria

Between March 2015 and May 2018, 94 patients under-went lumbar interbody fusion with pedicle screw fixation for the treatment of adult lumbar spondylolisthesis at the Department of Neurosurgery, Tanta University Hos-pital. Forty-six had PLIF with two cages and pedicle fixation (group 1), and 48 had TLIF with one cage and pedicle fixation (group 2). Inclusion criteria were as follows: single-level, low-grade (Meyerding grades I or II), isthmic or degenerative spondylolisthesis, and signifi-cant back and leg pain that failed conservative management.

Exclusion criteria were spondylolisthesis grades III and IV, instrumentation of more than two levels, a history of a previous fusion surgery to the lumbar spine, concomi-tant deformities of the spine (scoliosis, tumor, or trauma), and osteoporosis diagnosed by means of radi-ography and bone mineral density examination (T-score

≤2.5). Body mass index (BMI) [14] was calculated in all cases before surgery, and patients with BMI ≥40 (mor-bid obesity) were excluded from our study.

Informed consent was obtained from all participants. The choice of a lumbar fusion technique was individual-ized based on clinical needs of each patient, surgeon preferences, and patients’ request according to the in-formed consent and explanation of various surgical procedures. A summary of demographic and pre-operative data is presented in Table1.

Surgical technique

All patients were operated under general anesthesia and in prone position. All patients had single-level fusion performed. Brace support was recommended for up to 6–8 weeks after surgery.

PLIF

A midline skin incision was used. The fascia was incised and then the paravertebral muscles were dissected from the spine. Radiographs were used to confirm the appropriate vertebral level. Bilateral pedicle screw-rod constructs were then inserted, and a laminectomy was performed at that level. This was followed by bilateral foraminotomy and discectomy, and interbody graft placement. Cartilaginous material was removed from the endplates using an endplate scraper. Interbody fusion was performed with a polyetheretherketone (PEEK) cage filled with autologous bone graft on each side. A final fluoroscopy was performed as necessary to confirm

pedicle screw fixation and cage placement. The wound was profusely irrigated and closed in layers.

TLIF

A midline skin incision was performed. The muscles and soft tissues were retracted to expose the lateral aspect of the spinous process, the lamina, and the facet joint. Based on the clinical presentation, a unilateral laminec-tomy and partial faceteclaminec-tomy were performed on the side consistent with the patient’s symptoms. A bilateral laminectomy was done only for clinically significant bilateral neural element compression. After adequate de-compression of the neural elements has been performed, bilateral pedicle screws were placed in the standard fash-ion. Distraction of the disc space was performed using the four pedicle screws, and complete discectomy was done from one side using rongeurs and disc shavers. Table 1Patients’characteristics

Parameters PLIF group (N= 46)

TLIF group (N= 48)

Age (years)

Range 20–56 23–52

Mean ± SD 37.59 ± 8.84 38.75 ± 7.23

Gender

Male 15 (32.6%) 19 (39.6%)

Female 31 (67.4%) 29 (60.4%)

Follow-up, months

Range 6–30 6–32

Mean ± SD 20.24 ± 7.39 19.02 ± 5.03

VAS back (preoperative)

Range 5–9 5–9

Mean ± SD 7.00 ± 1.26 7.25 ± 1.28

VAS leg (preoperative)

Range 4–9 4–9

Mean ± SD 7.39 ± 1.24 6.75 ± 1.28

ODI (preoperative)

Range 34–79 32–77

Mean±SD 55.37±13.05 51.42±12.45

Grade of spondylolithesis

Grade I 25 cases (54.3%) 32 cases (66.7%)

Grade II 21 cases (45.7%) 16 cases (33.3%)

Type of spondylolithesis,n(%)

Degenerative 27 cases (58.7%) 25 cases (50%)

Isthmic 19 cases (41.3%) 23 cases (50%)

Affected level

L3–L4 4 (8.7%) 3 (6.2%)

L4–L5 25 (54.3%) 31 (64.6%)

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The bone chips obtained from laminectomy were inserted to fill the anterior third of the disc space, then a kidney-shaped cage filled with iliac bone graft was placed into the disc space. After insertion of bone grafts in both groups, the screws were tightened to the lordotic rod. Distraction or compression was added to achieve a good reduction in a proper lordotic curve. A closed drainage system was inserted in all cases, and wound closure was performed in layers.

Perioperative, clinical, and radiological assessments The study assessed perioperative results related to the operative procedure such as blood loss, operation time, hospital stay, and complications within 1 month postoperatively. Oswestry Disability Index (ODI) Questionnaires [15] were administered for functional evaluation, and the visual analog scale (VAS) [16] was used to assess pain preoperatively and postoperatively. Moreover, the same clinical parameters together with neurologic examination were evaluated at follow-up visits, which were scheduled 3, 6, and 12 months after the operation.

Radiographic evaluation included preoperative X-rays (standard lumbar anteroposterior/lateral, flexion/exten-sion views), computed tomography (CT), and magnetic resonance imaging (MRI).

Lumbosacral spine plain X-ray, including antero-posterior and lateral views, was obtained in all cases within 72 h after surgery to evaluate the position of screws and the cage. Static and dynamic radiographs were obtained 3 and 6 months postoperatively. All pa-tients underwent repeat X-ray and CT scan 1 year post-operatively. We compared pre- and postoperative radiographs. For the analysis, the postoperative radio-graphs included only the final radiograph at a minimum of 6 months after surgery.

The focus was to evaluate three radiographic charac-teristics at follow-up: (1) percentage of slip and percent-age of reduction, (2) cpercent-age and screws position, and (3) fusion rate.

The degree of spondylolisthesis was measured as a percentage of the distance from the posterior border of the caudal vertebra to the posterior border of the rostral vertebra, normalized to the superior end plate diameter of the former (Fig. 1). Slip reduction was defined as the difference between the pre- and post-operative spondylolisthesis. The reduction rate was calculated as follows:

Preoperative slippage distance−postoperative slippage distance

Preoperative slippage distance 100%:

Fusion rates were assessed with the Bridwell grading system by the final radiograph at a minimum of 6

months after surgery. The Bridwell system is com-posed of the following categories and grades [17]:

Grade I: fused with remodeling and trabeculae

present, grade II: graft intact but not fully remodeled and incorporated, with no lucencies above or below,

grade III: graft intact but with a definite lucency at

the top or bottom of the graft, and grade IV: defin-itely not fused, with resorption of bone graft and collapse. Both grades I and II were considered radio-graphic signs of solid fusion, and the fusion condition at the last follow-up was collected for analysis.

The criteria used to prove solid fusion inpatients were Trabeculae seen bridging the interbody gap with iso-dense bone in the cage and the adjacent vertebral bod-ies, anteriorand/or posterior sentinel signs, no lucencies around the pedicle screws, no lucencies around the cages, Integration of the cage with the endplates and silhouetting of the cage, and no evidence of motion on dynamic flexion and extension X-rays.

Statistical analysis

Data were expressed as mean ± standard deviation. Stat-istical analysis was done using Student T test with IBM SPSS Statistics for Windows, Version 21 (IBM Corp., Armonk, NY).

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Results

Clinical outcome

There were significant differences between the groups in relation to VAS for back pain and ODI. These variables were significantly higher in the TLIF group compared to the PLIF group. There was no significant difference be-tween the two groups with respect to VAS for leg pain at final follow-up (Table2).

Surgical time and blood loss

Estimated blood loss and operative time in the TLIF group were significantly lower than those in the PLIF group (P< 0.05) (Table2).

Reduction and fusion results

At the time of the last follow-up, both groups had similar slip reduction, and spinal fusion rates (P > .05). Spondylolisthesis slip reduction rate was 51.7913.59% in the TLIF group and 64.6810.87% in the PLIF group (P= 0.116). Solid fusion (Bridwell fusion grades I or II) was achieved in all patients (Figs.2and3). In total, 32 out of 46 patients (66.7%) in the TLIF group and 31 out of 48 (67.4%) patients in the PLIF group achieved grade I fusion, and all others achieved grade II fusion (Table3).

Operative and postoperative complications

In the PLIF group, there were five complications: two dural tears (repaired primarily), two neurologic deficit (postoperative weakness of great toe dorsiflexion, which was relieved spontaneously), and one deep wound infection (managed with debridement, drains, and intra-venous antibiotics).

A superficial infection was diagnosed in two patients in the TLIF group, which was treated conservatively. In the TLIF group, one patient experienced a dural tear without neurologic symptoms (repaired primarily).

All these complications did not lead to irreversible se-quelae. No perioperative complications in either group required revision surgery (Table2).

Discussion

Spondylolisthesis, either degenerative or isthmic type, is usually associated with radicular symptoms and back pain due to instability and compression [18,19], but sur-gical treatment of spondylolisthesis not only depends on decompression of neural tissue and stabilization of mo-tion segment but also reconstitumo-tion of disc space height and restoration of sagittal plane translational and rota-tional alignment are essential [20].

Interbody fusion is commonly used in surgical treatment of low-grade spondylolisthesis as it achieves solid fusion, preserves the disc height, maintains the load-bearing capacity, and reconstructs the anterior col-umn after disc evacuation [21–23].

PLIF or TLIF can achieve circumferential spinal stabilization by a single posterior approach [24], but TLIF usually requires unilateral exposure with less operative time and blood loss [25].In the current study, both the operative time and blood loss in PLIF was sig-nificantly higher compared to TLIF (p = 0.0004 and 0.0001, respectively). Liu et al. [26] have similarly re-ported that both the intraoperative time and blood loss volume were higher in the PLIF group than those of the TLIF group. This might be attributed to the necessity if

Table 2Comparison of surgical outcomes between PLIF and TLIF

Parameters PLIF group (n= 46) TLIF group (n= 48) Pvalue

Operation time (minutes) 127.39 ± 21.62 114.48 ± 13.26 0.0004

Blood loss (cm3) 456.96 ± 120.74 366.15 ± 78.49 0.0001

VAS back pre 7.00 ± 1.26 7.25 ± 1.28 0.1717

VAS back post 2.26 ± 1.00 1.77 ± 0.75 0.0044

VAS back change 4.74 ± 1.14 5.40 ± 1.18 0.0037

VAS leg pre 7.39 ± 1.24 7.17 ± 1.36 0.1752

VAS leg post 3.24 ± 1.18 2.98 ± 0.91 0.0824

VAS leg change 4.15 ± 1.44 4.19 ± 1.41 0.4245

ODI pre 51.42 ± 12.45 55.37 ± 13.05 0.0684

ODI post 16.85 ± 4.44 17.67 ± 7.33 0.2581

ODI change 33.98 ± 10.40 37.70 ± 10.61 0.0449

Postoperative complications (number of cases) 5 3

Dural tear 2 1

Nerve root injury (neurologic deficit) 2 0

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the bilateral exposure in PLIF compared to the unilateral exposure required in TLIF.

In the present work, the improvement of the VAS for back pain was significantly higher in the TLIF group compared to the PLIF group (p = 0.0037). This came in agreement with the work of El-Sayed et al. [27] who reported that the postoperative VAS for back pain was significantly improved in the TLIF group compared to the PLIF group. Nevertheless,

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statistically significant difference in VAS for pain at any time between the PLIF group and TLIF group.

In the current study, we could report a complication rate of 10.9% occurring in the PLIF group including a dural tear in 4.4% of cases, nerve root injury in another 4.4% of cases, and a deep wound infection in only 2.2% of them, but in TLIF group, there was a complication rate of only 6.3% including 4.2% of cases with a

superficial wound infection and 2.1% of them with a dural injury. Humphreys et al. [30] and Yehya [31] both evaluated the results of PLIF versus TLIF in their studies and reported that the complication rate in PLIF was higher than in TLIF. This might be attributed to the ne-cessity of bilateral exposure and excessive medial retrac-tion of the dura when placing the cage in the PLIF technique, which increases the incidence of neural Fig. 3PLIF procedure for the patient with degenerative L5 S1 spondylolisthesis. a Preoperative MRI. b Preoperative X-ray lateral view. c, d

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complications such as nerve injury, dural tear, and epi-dural scarring [32–34].

In our study, by the time of the last follow-up, both groups showed no significant difference in slip reduction and spinal fusion rate. Solid fusion was achieved in all cases including grade I fusion in 66.7% of cases in the TLIF group and 67.4% of cases in the PLIF group. Similarly, Yan et al. [35] in a comparative study between PLIF and TLIF, found that there was no significant dif-ference between both groups in slip reduction rate and that all patients have achieved spinal fusion with no case of cage extrusion. Nevertheless, in the study of Lee et al. [36], after 1 year of follow-up, fusion grade I was achieved in 61.9% of cases in TLIF group and in 63.3% in PLIF group without a statistically significant differ-ence between both groups.

Conclusion

The current study could show that TLIF is superior to PLIF with respect to the functional outcome and the complication rate in grade I/II single-level lumbar spondylolisthesis.

Abbreviations

BMI:body mass index; ODI: Oswestry Disability Index Questionnaires; PLIF: posterior lumbar interbody fusion; TLIF: transforaminal lumbar interbody fusion; VAS: visual analog scale

Acknowledgements

The authors sincerely thank the head of the Neurosurgery Department, Tanta Faculty of Medicine [Professor Ali Seif Eldeen] for his advice and support during performing the current work.

Authors’contributions

All authors have equally participated in designing the work and operating the patients. AE and IS have equally performed the data acquisition and analysis. ER has done the data interpretation and the scientific writing. All authors have thoroughly read, revised, and approved the final submitted manuscript.

Funding

The authors have no support or funding to report.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

Ethics approval was provided by the local Ethical Committee of the Faculty of Medicine, Tanta University. Reference number 32769 was obtained on the 26th of December 2018. Consent for participation was not applicable as this is a retrospective study, so the ethical committee waived the consent to participate.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Received: 29 December 2018 Accepted: 1 August 2019

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Table 3Slip reduction and fusion rate of spondylolisthesis

Parameters PLIF group (n= 46) TLIF group (n= 48) Pvalue

Degree of spondylolisthesis

Preoperative (%) 22.37 ± 10.20 18.08 ± 6.42 0.4968

Postoperative (%) 8.24 ± 5.32 8.71 ± 3.98 0.4511

Slip reduction (%) 64.68 ± 10.87 51.79 ± 13.59 0.1160

Fusion rate

Grade I Number 31 32

Rate % 67.4 66.7

Grade II Number 15 16

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Publisher’s Note

Figure

Table 1 Patients’ characteristics

Table 1

Patients’ characteristics p.2
Fig. 1 Degree of spondylolisthesis (%) = distance (2)/distance (1) ×100%. The spondylolisthesis degree was measured as a percentageof the distance from the posterior border of the caudal vertebra tothe posterior border of the rostral vertebra, normalized to thesuperior end plate diameter of the former
Fig. 1 Degree of spondylolisthesis (%) = distance (2)/distance (1) ×100%. The spondylolisthesis degree was measured as a percentageof the distance from the posterior border of the caudal vertebra tothe posterior border of the rostral vertebra, normalized to thesuperior end plate diameter of the former p.3
Table 2 Comparison of surgical outcomes between PLIF and TLIF

Table 2

Comparison of surgical outcomes between PLIF and TLIF p.4
Fig. 2 TLIF procedure for the patient with isthmic L5 S1 spondylolisthesis. a Preoperative X-ray lateral view
Fig. 2 TLIF procedure for the patient with isthmic L5 S1 spondylolisthesis. a Preoperative X-ray lateral view p.5
Fig. 3 PLIF procedure for the patient with degenerative L5 S1 spondylolisthesis. a Preoperative MRI
Fig. 3 PLIF procedure for the patient with degenerative L5 S1 spondylolisthesis. a Preoperative MRI p.6
Table 3 Slip reduction and fusion rate of spondylolisthesis

Table 3

Slip reduction and fusion rate of spondylolisthesis p.7

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